Diagnosis at first sight
Skin lesion and lymphangitis in an immunocompetent patient
Lesión cutánea y linfangitis en paciente inmunocompetente
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"482" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Leyre López-Soria, Koldo Aguirrebengoa Ibarguren, Juan Antonio Ratón Nieto, José Luis Barrios Andrés" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Leyre" "apellidos" => "López-Soria" "email" => array:1 [ 0 => "Leyremonica.lopezsoria@osakidetza.eus" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Koldo" "apellidos" => "Aguirrebengoa Ibarguren" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Juan Antonio" "apellidos" => "Ratón Nieto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "José Luis" "apellidos" => "Barrios Andrés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Enfermedades Infecciosas, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Cruces, Barakaldo, Vizcaya, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión cutánea y linfangitis en paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 689 "Ancho" => 905 "Tamanyo" => 55549 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cerebriform colonies of <span class="elsevierStyleItalic">T. verrucosum</span> in chocolate agar after 10 days of incubation at 37<span class="elsevierStyleHsp" style=""></span>°C.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This was a 42-year-old patient with no relevant medical history who came to the hospital with a skin lesion on the left leg and feeling shivery. He reported the appearance, two months earlier, of a non-pruritic, scaly erythematous plaque on his left knee. On examination, an infected rounded plaque with desquamating borders was found on the lateral aspect of the left knee with several abscessed points, as well as signs of cellulitis and lymphangitis in the thigh (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Several hard, mobile and painful enlarged lymph nodes were found in the left inguinal region. The patient lived in the country in contact with cows, goats and horses, and reported falling off a horse onto brambles. After prescribing IV treatment with amoxicillin-clavulanic acid, the patient was admitted to the infectious diseases unit with a differential diagnosis of mycobacterial infection vs nocardiosis. A biopsy of the lesion was taken for histological and microbiological study. A small desquamative erythematous lesion was also found in the right pretibial area, but without signs of infection. The patient was discharged 48<span class="elsevierStyleHsp" style=""></span>h after admission with amoxicillin-clavulanic acid and cotrimoxazole.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Outcome</span><p id="par0010" class="elsevierStylePara elsevierViewall">After 7–10 days of incubation, the pure growth of a filamentous fungus forming creamy cerebriform colonies was observed in the cultures of exudate, abscess and biopsy from the patient's knee lesion in chocolate agar medium and blood agar at 37<span class="elsevierStyleHsp" style=""></span>°C (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The antibiotic treatment was therefore discontinued and treatment with oral terbinafine was prescribed. Days later, growth was observed in Sabouraud medium with chloramphenicol and gentamicin at 30<span class="elsevierStyleHsp" style=""></span>°C. Microscopic examination showed hyphae with chandelier appearance, absence of macroconidia and microconidia, and the presence of long chains of compacted chlamydoconidia suggestive of <span class="elsevierStyleItalic">Trichophyton verrucosum</span> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The histological study showed an inflammatory process in the dermis with follicular destruction and presence of PAS-positive rounded structures, compatible with Majocchi granuloma. After six weeks of treatment, the lesion on the right tibia progressed to cellulitis with small pustular lesions and signs of lymphangitis. In the culture of one of the lesions, <span class="elsevierStyleItalic">T. verrucosum</span> was isolated again, with identification confirmed by the sequencing of the ITS region of the rRNA. Finally, after 12 weeks of treatment with terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg/d, the lesions had completely disappeared and the patient was discharged with no abnormal laboratory test results.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Comments</span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Trichophyton verrucosum</span> is a zoophilic dermatophyte fungus of cosmopolitan distribution which causes inflammatory tinea infections through direct or indirect exposure with cattle and less commonly with other animals. The prevalence of the infection in humans varies greatly depending on the geographic area studied<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> and has been related to different milking practices, humidity, hygiene conditions and animal vaccination programmes in the area. The most common forms of clinical presentation are <span class="elsevierStyleItalic">tinea corporis, tinea capitis</span> and <span class="elsevierStyleItalic">tinea barbae</span> (kerion).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> Majocchi granuloma is a form of dermatophytosis in which the fungus invades the dermis and destroys the hair follicle. It is very uncommon and is usually seen in patients with either trauma or immunosuppression factors, and in these cases it can spread via the lymphatic or vascular systems or by contact.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5–8</span></a> The differential diagnosis of this clinical condition includes infection by <span class="elsevierStyleItalic">Nocardia</span> spp., atypical mycobacteria or other mycoses, especially in patients with lesions in the extremities and who spend time in rural areas. The definitive diagnosis is determined by the requirements of the fungus, as the optimum temperature for growth is 37<span class="elsevierStyleHsp" style=""></span>°C, and it needs media enriched with thiamine or inositol. This means growth is slow and it is not uncommon to detect it in bacteriological media, such as blood, chocolate or BHI agar.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The antifungals most often used for the treatment of these severe forms of dermatophytosis are terbinafine and triazoles, and the duration of treatment is determined by the clinical response and host factors.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, we present a rare case of invasive dermatophytosis caused by <span class="elsevierStyleItalic">T. verrucosum</span> in an immunocompetent patient, probably acquired through direct contact with a sick animal or spores in the soil or fomites. The inflammatory reaction in mycosis caused by <span class="elsevierStyleItalic">T. verrucosum</span> and the difficulty the fungus has in recovering in mycological culture media can lead to the delayed diagnosis of this infection.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Outcome" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Comments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López-Soria L, Aguirrebengoa Ibarguren K, Ratón Nieto JA, Barrios Andrés JL. Lesión cutánea y linfangitis en paciente inmunocompetente. Enferm Infecc Microbiol Clin. 2019;37:481–482.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1037 "Ancho" => 905 "Tamanyo" => 88252 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infected left knee lesion with desquamating borders.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 689 "Ancho" => 905 "Tamanyo" => 55549 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cerebriform colonies of <span class="elsevierStyleItalic">T. verrucosum</span> in chocolate agar after 10 days of incubation at 37<span class="elsevierStyleHsp" style=""></span>°C.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 706 "Ancho" => 905 "Tamanyo" => 82286 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chlamydoconidia chains characteristic of <span class="elsevierStyleItalic">T. verrucosum</span> in the microscopic examination with lactophenol blue (×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Updates on the epidemiology of dermatophyte infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 25 | 2 | 27 |
| 2024 September | 41 | 8 | 49 |
| 2024 August | 55 | 6 | 61 |
| 2024 July | 59 | 5 | 64 |
| 2024 June | 51 | 5 | 56 |
| 2024 May | 28 | 3 | 31 |
| 2024 April | 20 | 7 | 27 |
| 2024 March | 41 | 2 | 43 |
| 2024 February | 28 | 5 | 33 |
| 2024 January | 39 | 3 | 42 |
| 2023 December | 22 | 3 | 25 |
| 2023 November | 30 | 3 | 33 |
| 2023 October | 50 | 6 | 56 |
| 2023 September | 14 | 1 | 15 |
| 2023 August | 24 | 1 | 25 |
| 2023 July | 14 | 7 | 21 |
| 2023 June | 37 | 0 | 37 |
| 2023 May | 41 | 4 | 45 |
| 2023 April | 49 | 2 | 51 |
| 2023 March | 45 | 7 | 52 |
| 2023 February | 33 | 2 | 35 |
| 2023 January | 68 | 4 | 72 |
| 2022 December | 31 | 6 | 37 |
| 2022 November | 54 | 7 | 61 |
| 2022 October | 27 | 7 | 34 |
| 2022 September | 35 | 10 | 45 |
| 2022 August | 23 | 5 | 28 |
| 2022 July | 39 | 6 | 45 |
| 2022 June | 25 | 5 | 30 |
| 2022 May | 21 | 9 | 30 |
| 2022 April | 33 | 6 | 39 |
| 2022 March | 29 | 8 | 37 |
| 2022 February | 42 | 3 | 45 |
| 2022 January | 38 | 6 | 44 |
| 2021 December | 25 | 8 | 33 |
| 2021 November | 28 | 9 | 37 |
| 2021 October | 23 | 10 | 33 |
| 2021 September | 17 | 8 | 25 |
| 2021 August | 30 | 7 | 37 |
| 2021 July | 15 | 7 | 22 |
| 2021 June | 17 | 8 | 25 |
| 2021 May | 15 | 9 | 24 |
| 2021 April | 29 | 11 | 40 |
| 2021 March | 21 | 5 | 26 |
| 2021 February | 16 | 9 | 25 |
| 2021 January | 21 | 7 | 28 |
| 2020 December | 23 | 7 | 30 |
| 2020 November | 23 | 2 | 25 |
| 2020 October | 19 | 1 | 20 |
| 2020 September | 18 | 9 | 27 |
| 2020 August | 15 | 8 | 23 |
| 2020 July | 21 | 2 | 23 |
| 2020 June | 17 | 9 | 26 |
| 2020 May | 23 | 7 | 30 |
| 2020 April | 7 | 1 | 8 |
| 2020 March | 15 | 5 | 20 |
| 2020 February | 15 | 7 | 22 |
| 2020 January | 0 | 1 | 1 |
| 2019 September | 1 | 0 | 1 |
| 2019 August | 1 | 0 | 1 |
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